Creevelea House Nursing Home inspection report, 7-8 March 2011

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1 Creevelea House Nursing Home inspection report, 7-8 March 2011 Item type Authors Publisher Report Health Information and Quality Authority (HIQA); Social Services Inspectorate (SSI) Health Information and Quality Authority (HIQA), Social Services Inspectorate (SSI) Downloaded 9-May :24:42 Link to item Find this and similar works at -

2 & Health Information and Quality Authority Social Services Inspectorate Inspection report Designated centres for older people Centre name: Creevelea House Nursing Home Centre ID: 0129 Centre address: Laytown Co. Meath Telephone number: Fax number: address: Type of centre: Private Voluntary Public Registered provider: Person in charge: Creevelea House Ltd Ms Ashmi Cheriam (Acting) Date of inspection: 07 and 08 March 2011 Time inspection took place: Lead inspector: Support Inspector: Day 1: Start: 10:30 hrs Day 2: Start: 06:40 hrs Nuala Rafferty N/A Completion: 15:30 hrs Completion: 08:00 hrs Purpose of this inspection visit Application to vary registration conditions Notification of a significant incident or event Notification of a change in circumstance Information received in relation to a complaint or concern Follow-up inspection Page 1 of 40

3 About the inspection The purpose of inspection is to gather evidence on which to make judgments about the fitness of the registered provider and to report on the quality of the service. This is to ensure that providers are complying with the requirements and conditions of their registration and meet the Standards, that they have systems in place to both safeguard the welfare of service users and to provide information and evidence of good and poor practice. In assessing the overall quality of the service provided, inspectors examine how well the provider has met the requirements of the Health Act 2007, the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) and the National Quality Standards for Residential Care Settings for Older People in Ireland. Additional inspections take place under the following circumstances: to follow-up matters arising from a previous inspection to ensure that actions required of the provider have been taken following a notification to the Health Information and Quality Authority s Social Services Inspectorate of a change in circumstance for example, that a provider has appointed a new person in charge arising from a number of events including information received in relation to a concern/complaint or notification to the SSI of a significant event affecting the safety or well-being of residents to randomly spot check the service All inspections can be announced or unannounced, depending on the reason for the inspection and may take place at any time of day or night. All inspection reports produced by the Health Information and Quality Authority will be published. However, in cases where legal or enforcement activity may arise from the findings of an inspection, the publication of a report will be delayed until that activity is resolved. The reason for this is that the publication of a report may prejudice any proceedings by putting evidence into the public domain. Page 2 of 40

4 About the centre Description of services and premises Creevelea House Nursing Home is a converted residential dwelling house providing care to persons up to and over 65 years with a range of complex needs which includes dementia care, challenging behaviour, physical and intellectual disabilities, mental health issues and end of life care. The centre provides care for up to 44 residents. It is a single-story building consisting of 25 single (one bedroom has been converted into an office space and two other single rooms are now being used as a clinical room and store room) three twin-bedded, three three-bedded and one four-bedded bedrooms. Two of the three-bedded rooms share an en suite shower, wash-hand basin and toilet. The four-bedded room has an en suite toilet and wash-hand basin. The remaining bedrooms do not have en suite facilities. Other facilities include a small porch, a hallway, two sitting rooms, one dining room, one visitors room with conservatory, one main kitchen, a laundry, a sluice room, three store rooms, one nurses office, one office for the person in charge and an administration office, one staff changing area, an oratory, four assisted toilets, one nonassisted toilet, three assisted showers, one non-assisted shower and one assisted bath. The centre is surrounded by a low wall at the front with two entrances/exits overlooking the sea. The centre is situated on approximately two acres which consists of a small front and large rear garden. The rear garden is enclosed by two six-foot high walls at the sides and a wooden fence at the back. It is predominantly lawned, with a small perimeter pavement around the edges of the building. There is a small enclosed garden for residents use. There are a limited number of parking spaces at the main entrance and delivery entrance for staff and visitors use. Location Creevelea House is situated on the main Laytown to Bettystown Road in County Meath. Date centre was first established: Number of residents' on the date of inspection Number of vacancies on the date of inspection *6 *person in charge stated the provider was reducing beds currently from 44 to 36 and therefore there were only six vacant beds in the centre. Page 3 of 40

5 Dependency level of Max High Medium Low current residents Number of residents Management structure Creevelea House Nursing Home is owned by Creevelea House Limited. The nominated person on behalf of the Provider is Mr. Peter Murphy. The post of Person in Charge is currently vacant. The recently appointed clinical nurse manager Ms. Ashmi Cheriam is acting as Person in Charge. All staff including nursing, care, household and ancillary report directly to the acting person in charge who reports to Mr. Murphy. Staff designation Number of staff on duty on day of inspection Person in Charge Nurses Care staff Catering staff Cleaning and laundry staff Admin staff Other staff * * acting person in charge on duty Page 4 of 40

6 Background Creevelea House Nursing Home was first inspected by the Health Information and Quality Authority (the Authority) on 31 March 2010 and 1 April This was a triggered, unannounced inspection in response to information received by (the Authority). As a result of findings on the inspection, three subsequent follow up inspections were carried out on 02, 05 and 13 April 2010 to monitor the service. The report for this inspection can be found on Further inspections were carried out on 07 May 2010 and 16 June 2010 to monitor the care and welfare of residents. The provider attended a meeting with the Authority in their Dublin Regional Office in April and July 2010 to discuss ongoing concerns. A registration inspection was carried out on 29 and 30 November and 1 December 2010 and further follow up inspections on 3, 7, 14 and 23 December Inspectors found risks to the health and welfare of residents due to a failure by the provider to meet the requirements of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) and the National Quality Standards for Residential Care Settings for Older People in Ireland. There were significant concerns for the care and welfare of residents due to: failure to ensure the general welfare and protection of residents lack of suitable and sufficient care lack of governance During the inspection the provider was required to take immediate action to address these issues, particularly in relation to the lack of heat in the centre, the safety and security of the premises further to two recent unauthorised entries, several power outages and a gas leak. Inspectors also identified that significant improvements were required in relation to maintaining the safety of residents, the transparency of financial processes and contingency arrangements in the event of an emergency. Further improvements were also required in the area of risk management, recruitment and vetting, the quality of assessment and care planning for residents presenting with complex needs and the design, layout and maintenance of the premises. Subsequent to the follow up visit on 23 December 2010, a second emergency Action Plan was issued to the provider in relation to a smell of gas from defective equipment in the kitchen. Page 5 of 40

7 A plan consisting of actions was developed by the inspection team based on their findings where some or significant improvement was required by the provider. This additional inspection report outlines the findings of a follow up inspection that took place on 07 and 08 March The inspection was unannounced and focused on the implementation of some of the action plan issued to the provider. Summary of findings from this inspection This follow up inspection reviewed a total of 13 actions from the registration inspection. The provider had completed one, partially completed three and not completed nine out of the 13 actions required by the Authority. During the course of the inspection further issues were noted which were of serious concern in relation to: lack of suitable and sufficient care healthcare needs appropriate staffing maintenance infection prevention and control An emergency action plan was issued to the provider at the conclusion of the inspection and a further action plan has been developed requiring the provider to address these areas in line with legislation and standards. Page 6 of 40

8 Issues covered on inspection: A lack of suitable and sufficient care in relation to the management of one resident with a terminal illness was found. The inspector was informed by the acting person in charge that this resident s condition was deteriorating. However, evidence of appropriate, regular medical review and management of the residents condition was not found. This is further referenced under actions 9 and 10 detailed at the end of this report. As a result of the Authority s ongoing concerns regarding the welfare of residents, an emergency action plan was issued to the provider further to the second day of inspection on 08 March Evidence that resident s healthcare and specifically dietary needs were being met was not found. The chef on duty was not provided with a diet list and although aware that 15 residents were on soft diets could not tell the inspector how many diabetic diets were required or whether any other resident had special dietary needs. The recording of food and fluid intake was not in place to determine residents nutritional intake on an ongoing basis as indicated by changes in the resident s condition such as frequent vomiting. Infection prevention and control practices were not appropriate. The main kitchen was not clean. The floor was unswept, unwashed and dirty with food particles and grime. When walking into the dry goods store the inspector found her shoes sticking to the floor. The wall tiles above the wash-hand basin were caked with grime and spillage from the soap dispenser. The alcohol gel disinfectant dispenser beside the wash-hand basin was empty. On enquiry the chef was not aware of or implementing a cleaning schedule for the kitchen. The wall behind the recently installed gas cooker was bare concrete and was black with dirt and grease. The catering assistant was moving between the kitchen and the dining room without use of personal protective equipment such as gloves, hat or apron. Appropriate staffing levels qualifications and skill mix were not found on the days of inspection. The catering staff on duty did not have up to date training in basic food hygiene or hazard analysis and critical control points as required under health and safety legislation. The level of staff in the catering department was not sufficient. On the second morning of inspection it was noted that the care staff on night duty prepare and serve breakfast to some residents between 07:00 hrs and 08:00 hrs leaving one nurse to deliver direct care to 28 residents. Ongoing maintenance issues were noted. Items of equipment requiring repair such as the dishwasher in the kitchen which was broken since the previous Wednesday (six days previously) and was not yet repaired. This meant that the catering assistant was washing all dishes by hand and the chef was washing all pots and pans by hand. Despite recurrent and new maintenance problems within the centre, the maintenance person was now only working part time three days per week. Page 7 of 40

9 Safe and appropriate management of clinical waste was not found. Two large clinical waste bins were provided for the disposal of clinical waste material. These bins were found to be partially full of waste and unlocked in the centre grounds. Page 8 of 40

10 Actions reviewed on inspection: 1. Action required from previous inspection: The provider shall transfer residents in danger of hypothermia and provide suitable accommodation to meet their needs. The provider shall ensure that an appropriate emergency response plan which meets the needs of residents is devised and implemented immediately. This action was partially addressed. This action was issued as an emergency action to the provider during the registration inspection on 01 December On subsequent follow-up inspections in December 2010 the action was found to be partially addressed in that heating in the centre was maintained at an appropriate level and room temperatures were checked on a regular basis. However, to date the emergency action plan for the centre has not been revised and an appropriate emergency response plan was not in place. Action required from previous inspection: The provider shall put in place all and any measures required to resolve the gas leak. The provider shall put in place alternative measures for providing cooked meals to residents which does not compromise residents or staff in terms of health and safety. The provider shall ensure that an appropriate emergency response plan which meets the needs of residents is devised and implemented immediately. This action was partially addressed. This action was issued as an emergency action to the provider during the follow-up inspection on 23 December The defective gas cooker had been replaced. A new gas cooker had been installed and in use however, evidence that it was commissioned for safe use by the installation company was not available. An electric cooker was provided as an alternative for use when the gas cooker was being replaced. The provider did not identify any measures to resolve the gas leak in his action plan response and this aspect of the action required could not be inspected. Therefore evidence that the gas leak had been resolved was not available. Page 9 of 40

11 3. Action required from previous inspection: Immediately replace all seriously defective equipment specifically the gas cooker, and repair or replace all other equipment currently not in full working order such as (but not exclusively) the main boiler, water pipes and electrical fuse boards. Provide safe and secure premises and equipment which ensures the general welfare and protection of residents at all times and complies with all relevant statutory provisions including health and safety, building and fire legislation. Establish clear policies and procedures on the provision and ongoing maintenance of the premises and equipment which meets evidence based practice and relevant statutory legislation. Ensure all staff are knowledgeable in respect of these policies and procedures. Establish safe systems for regular monitoring and review of all replacement, repair and maintenance programmes. Initiate an immediate and thorough review of all aspects of the premises and equipment both internal and external and make a report on these reviews to the Authority within three months of receipt of this report. This review to be undertaken by persons with relevant expertise and qualifications and to include recommendations for improvement within reasonable timeframes. Undertake to implement all recommendations made by the qualified persons in the review within a reasonable timeframe to be agreed by the Authority. This action was partially addressed. The gas cooker was replaced and a review of the electrical system in the centre was carried out on the 18 February The electrical system review identified eight remedial actions were required of which five were urgent and six showed non compliance with current national rules for electrical installations. An internal action plan identifying progress on a list of issues found as a result of the registration inspection was viewed. Evidence of repair or review of the main boiler and review of heating, insulation and water pipes within the centre was not available. 4. Action required from previous inspection: Provide safe and secure premises, equipment and staffing which ensures the general welfare and protection of residents at all times through the provision of adequate security and all other protective measures as may be required. Ensure all protective measures currently in place are implemented at all times and that staff are familiar with and knowledgeable on all such measures. Establish clear policies and procedures on the provision and ongoing review of security and protection of residents and staff under health and safety and all other relevant legislative requirements. Page 10 of 40

12 Ensure all staff are knowledgeable in respect of these policies and procedures. Establish safe systems for monitoring and reviewing all safety systems and protective measures put in place. Establish a system which audits and reviews such safety systems and protective measures on a regular basis and no less frequently than annually. Initiate an immediate and thorough review of all aspects of the premises and equipment both internal and external and make a report on these reviews to the Authority within three months of receipt of this report. This review to be undertaken by persons with relevant expertise and qualifications and to include recommendations for improvement within reasonable timeframes. Undertake to implement all recommendations made by the qualified persons in the review within a reasonable timeframe to be agreed by the Authority. This action was not addressed. On the afternoon of the first day of follow-up inspection the door at the rear of the building which was used as a staff entry/exit point was found to be fully open. This access was previously identified as a safety risk and an intruder was seen by staff in this area during the week prior to the registration inspection in November As a result a key code system was placed on the door to improve security for residents and staff. However, this protective measure was not being implemented and monitoring of these protective measures was not found. The inspector viewed a report written following a review of the security of the centre undertaken by the local crime prevention Officer of An Garda Síochána on 09 February The report identified a number of recommendations which included provision of a CCTV system, an alarm system, a review of access to the staff entry/exit point at the rear of the building, office staff security and replace fencing at the rear of the building. The action plan response from the provider stated that window restrictors would be fitted to all windows and quotes for personal alarm systems and magnetic locks in addition to enquiries to secure the side gate and the fencing to the rear of the building. However, timeframes for completion or assurances that the review by the crime prevention officer would be implemented were not stated and so could not be evidenced. Page 11 of 40

13 5. Action required from previous inspection: Develop a comprehensive emergency plan for responding to all types of emergencies including loss of power and heat. Ensure all resources available, specific contact details and arrangements to evacuate residents if required are included. Ensure all staff are knowledgeable in respect of the emergency plan and competent in terms of the implementation of the plan. Establish a system to review the emergency plan on a regular basis and no less frequently than every three months. This action was not addressed. The person in charge stated the emergency plan was not yet revised but stated that all of the actions required in the registration report would be completed by the end of March Action required from previous inspection: Implement the Challenging Behaviour policy in full and develop individual assessment and individual intervention plans for all residents who present with behaviour that challenges. Review supervision systems and practices in place to manage challenging behaviour in communal and private bedroom areas which ensures safety and also respects the privacy and dignity of all residents. Establish a system which audits and reviews implementation of the policy and disseminates learning to all staff. This action was not addressed. On review of the documentation for two residents identified as exhibiting aspects of challenging behaviour, revised individual assessments and intervention plans were not found to be in place. For example, one resident continued to wander, particularly late at night and both residents exhibited signs of agitation and aggression manifested through verbal outbursts and shouting. Evidence of a review of supervision practices and systems was not found and the most recent evidence of regular supervision checks on the resident who wanders were dated 17 and 18 November Page 12 of 40

14 7. Action required from previous inspection: Ensure by means of fire drills and practices at suitable intervals that all persons working in the centre are aware of and competent in the procedures to be followed in the event of a fire. Establish a system of regular review and audit of all fire practices and procedures which includes determination of staff knowledge. Where reasonably practicable ensure residents are aware of the procedures to be followed in the event of a fire. This action was not addressed. The inspector spoke with three staff members on the procedures to be followed in the event of a fire (two of whom were recently appointed). The newly appointed nurse knew where the fire panel and assembly point were situated in the event of a fire and told the inspectors she had been given an overview of fire procedures during her induction at the beginning of February. However, neither of the other staff were knowledgeable of the procedure to be followed in the event of a fire. The other new staff member said she was not aware of the fire procedure or emergency plan. The other staff person said she had received training in fire safety but could not tell the inspector where the assembly point was or what she would do if the fire alarm activated. Adequate arrangements for safe evacuation were not in place. The person in charge informed the inspector that 16 new evacuation sheets had been purchased. However, the inspector noted that they were not in place on residents beds for use in the event of an emergency. 8. Action required from previous inspection: Ensure each resident has their needs set out in an individual care plan and keep it under formal review as required by the resident s changing needs or circumstances and no less frequently than every three months. Put systems in place to ensure that all residents identified needs are set out in an individual care plan developed and agreed with each resident. Ensure that all issues such as falls, risks or challenging behaviour are addressed in the care plan and that the care plan is adequately specific to address the need identified. Ensure that care plans in place consistently reflect residents current health status. This action was not addressed. Page 13 of 40

15 On review of a sample number of residents care plans inspectors found that a care plan was not in place for every identified need, care plans in place were not specific enough to address or manage the identified need and were not reviewed as required by residents changing needs. For example, inspectors found one residents with a terminal illness did not have care plans in place in relation to end of life care. Although nurse progress notes referenced palliative care team liaison a care plan for management of palliative care needs was not in place. Care plans were not reviewed as required by residents changing needs. For example, a care plan for this same resident included the need to monitor for signs of infection and identified possible indicators as being increased confusion and falls. However, despite recent recurrent falls evidence of monitoring for infection, such as urinalysis was not found. 9. Action required from previous inspection: All necessary information relating to the residents health, personal and social care needs is obtained prior to admission. Establish and maintain protocols which ensure appropriate continuity of care for all residents further to admission. Review and audit such systems and processes established to ensure ongoing implementation. This action was not addressed The inspector reviewed documentation of one resident admitted in November 2010, a pre-admission assessment was carried out which included health, personal and social care needs. However, evidence of a medical referral note or admission letter reflecting the residents medical status at time of admission was not found. Evidence that the resident was reviewed further to admission and on a regular basis thereafter was not found. In the case of this one resident further to admission, the first documented review by a general practitioner (GP) was on 14 February 2011 some four months later. 10. Action required from previous inspection: Ensure all residents are facilitated to access relevant health care services as may be required. Ensure all residents are provided with appropriate medical care which includes regular three monthly reviews of residents general condition and medication. Provide such services as may be required or enter into discussion with the health service executive to ensure the ongoing provision of services and/or supports which meets the needs of all residents in the current residents profile. Page 14 of 40

16 This action was not addressed. The inspector reviewed the nurse progress notes for one resident and noted that the resident had been vomiting on an almost daily basis over the previous week, the GP was informed but did not visit the centre to review the resident s care. Despite nurse progress notes referencing the need for palliative care inputs no evidence of review by a palliative care team was found. 11. Action required from previous inspection: Establish best practice procedures in the moving and handling of residents, to include assessment of residents, individual moving and handling plans, staff training and monitoring of practice. This action was addressed. Some improvements in moving and handling practices were found. Inspector observed residents being transferred by staff who used assistive devices such as mechanical hoists and transfer belts to transfer residents safely. 12. Action required from previous inspection: Provide all staff with training that maintains skills and ensures they are competent to carry out their role. Ensure that staff members have access to education and training to enable them to provide care in accordance with contemporary evidence-based practice. Establish systems which monitors, reviews and audits learning achieved and ensures staff are competent in all aspects of their role. Ensure the staff training plan is linked to staff appraisals and performance management development assessments. This action was not addressed. In conversation with staff and on review of records the inspector found that all catering staff were not provided with training in basic food hygiene or hazard analysis and critical control points commensurate with their role. Not all newly-appointed staff were provided with an induction process which included overview of fire procedures and evidence of mandatory training in moving and handling for all staff including those recently appointed was not found. Page 15 of 40

17 13. Action required from previous inspection: Ensure that all staff records contain all the requirements listed in schedule 2 of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended). This action was not addressed. On review of a sample of staff personnel records it was found they did not meet all of the legislative requirements in that, photograph identification and evidence of medical fitness from a qualified medical practitioner were not available. Inspectors also noted that where references were available, there was no evidence of these having been checked by the provider prior to staff commencing employment and the inspector noted that for some staff the majority of references provided were between 11 and 20 years old. Evidence that all nurses employed were suitably qualified and registered with An Bord Altranais was not available. Report compiled by: Nuala Rafferty Inspector of Social Services Social Services Inspectorate Health Information and Quality Authority Date: 11 March 2011 Page 16 of 40

18 Chronology of previous HIQA inspections Date of previous inspection Type of inspection: 31 March 2010, 1, 2, 5 and 13 April 2010 May 2010 June 2010 August 2010 Registration Scheduled Follow up inspection Announced Unannounced Registration Scheduled Follow up inspection Announced Unannounced Registration Scheduled Follow up inspection Announced Unannounced Registration Scheduled Follow up inspection Announced Unannounced 29, 30 November 1 December 2010 Registration Scheduled Follow up inspection Announced Unannounced 3,7 14 and 23 December 2010 Registration Scheduled Follow up inspection Announced Unannounced Page 17 of 40

19 Health Information and Quality Authority Social Services Inspectorate Action Plan Provider s response to additional inspection report * Centre: Creevelea House Nursing Home Centre ID: 129 Date of inspection: 7 and 8 March 2011 Date of response: 15 April 2011 Requirements These requirements set out what the registered provider must do to meet the Health Act 2007, the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) and the National Quality Standards for Residential Care Settings for Older People in Ireland. Action plan 1 refers to the Emergency action plan issued to the provider on 8 March The provider has failed to comply with a regulatory requirement in the following respect: All reasonable measures were not put in place to provide suitable and sufficient care for one identified resident. Ensure suitable and sufficient care is put in place. Ensure a full medical review is carried out immediately. * The Authority reserves the right to edit responses received for reasons including: clarity; completeness; and, compliance with legal norms. Page 18 of 40

20 Ensure appropriate palliative care interventions are put in place immediately. Reference: Health Act, 2007 Regulation 9: Health Care Standard 13: Healthcare Standard 16: End of Life Care Please state the actions you have taken or are planning to take with timescales: Timescale: Provider s response: All residents in the home are reviewed by their own GP (more often according to the changing health needs of the residents). The named resident admitted to CHNH on 1 November 2010 with diagnosis of CA BOWEL and was under palliative care coordinated by her GP at the time of admission and she was reviewed by the GP on 18 November 2010 (and also went for an appointment in his surgery on 19 November 2010). Supervision was always provided for the resident by staff. All risk assessments were carried out for the resident by the nursing staff. On plenty of occasions nursing staff contacted palliative care team earlier this year but is awaiting their visit. By the end of January confirmation was received outlining who the resident s assigned doctor would be after trying to get a GP nearby. Ongoing Again on February 2011, nursing staff tried to contact palliative care team a few times and they came to see her on 7 February The resident was seen by own GP on a few occasions and the blood samples were taken for fbc and bioprofile. Later nursing staff were informed by the GP on 18 February 2011 that her HB was a little bit low and he wanted to increase her Galfer tan twice daily. The resident always had a good appetite and supervision provided at mealtimes. She was on pain control drugs and all nursing staff were aware to monitor her closely. All her personal hygiene needs were met appropriately (the resident was offered a shower on a daily basis and alcohol free wipes provided for hygienic needs). All her dietary needs were met time to time, was on supplement drinks. An intake chart was maintained after the resident had few episodes of vomiting on the first week of March. (after episodes of falls, the resident was sent for x-ray and the information received was NAD from hospital). Page 19 of 40

21 The resident s GP was contacted few times for review and he came to see her on 9 March 2011 and was happy with her and he informed nursing staff that he arranged a physio service for her for the next day. (nil pain when asked /vomiting noted that day). Staff always encouraged the resident to take more fluids and staff are aware about her disease condition and changing needs 2. The provider has failed to comply with a regulatory requirement in the following respect: All reasonable measures had not been taken to maintain residents welfare and wellbeing. The provider shall ensure that an appropriate emergency response plan which meets the needs of residents is devised and implemented immediately. The provider shall put in place all and any measures required to resolve the gas leak. Reference: Health Act, 2007 Regulation 6: General Welfare and Protection Standard: 8: Protection Please state the actions you have taken or are planning to take with timescales: Provider s response: The gas supply from the exterior tank source to and including the cooker was checked and certified safe for use by suitably qualified gas technicians earlier last year (tank and piping 15 July 2010, cooker 21 July 2010). Timescale: Completed A new eight burner gas cooker containing improved safety devices was installed 25 February A commissioning certificate was received confirming correct and safe installation with no gas leaks (25 February 2011). Training of appropriate staff was provided. To double check, the gas technician has been requested to re-check the supply from tank to new cooker. 22 April 2011 Page 20 of 40

22 3. The provider has failed to comply with a regulatory requirement in the following respect: The premises had not been suitably maintained in a good state of repair and equipment had not been maintained in good working order. Immediately replace all seriously defective equipment specifically the gas cooker, and repair or replace all other equipment currently not in full working order such as (but not exclusively) the main boiler, water pipes and electrical fuse boards. Provide safe and secure premises and equipment which ensures the general welfare and protection of residents at all times and complies with all relevant statutory provisions including health and safety, building and fire legislation. Establish clear policies and procedures on the provision and ongoing maintenance of the premises and equipment which meets evidence based practice and relevant statutory legislation. Ensure all staff are knowledgeable in respect of these policies and procedures. Establish safe systems for regular monitoring and review of all replacement, repair and maintenance programmes. Initiate an immediate and thorough review of all aspects of the premises and equipment both internal and external and make a report on these reviews to the Authority within three months of receipt of this report. This review to be undertaken by persons with relevant expertise and qualifications and to include recommendations for improvement within reasonable timeframes. Page 21 of 40

23 Undertake to implement all recommendations made by the qualified persons in the review within a reasonable timeframe to be agreed by the Authority. Reference: Health Act, 2007 Regulation 19: Premises Standard 25: Physical Environment Please state the actions you have taken or are planning to take with timescales: Timescale: Provider s response: The gas cooker was defective in that one oven (of two) did not work. A new eight burner gas cooker containing improved safety devices was installed 25 February Completed Completed A commissioning certificate was received confirming correct and safe installation with no gas leaks 25 February Training of appropriate staff was provided. Water pipes in full working order. The one external pipe that did burst during the cold spell was replaced. Further external insulation is being considered by the maintenance man. Electrical fuse boards in full working order. Following electrical system review certain fuse boards and cabling being updated to meet the most recent safety recommendations at the highest level. A policy and procedure for ongoing maintenance was developed. The policy indicates who is responsible for which aspect of maintenance and highlights staff responsibility in reporting maintenance issues as they pertain to health and safety. Staff being asked to read the sections pertinent to their role. Updated electrical work to be completed May February 2011 April/May 2011 All equipment certificates are up to date. Review of electrical and security systems sent to the Authority. Follow up implementation in progress. Plumbing and boiler reviews led to direct work being completed. The boiler system was reviewed and all three boilers were comprehensively serviced. The boilers were certified and a service contract is in place. The boilers now operate at a temperature using an automatic temperature monitoring control system based on the outside temperature; the lower the temperature of the external air the Page 22 of 40

24 greater the amount of heat delivered (the previous system relied on three manual heat settings). Following the plumbing review: thermostatic valves fitted to radiators. Water mixing valves being fitted under sinks in all rooms. 4. The provider has failed to comply with a regulatory requirement in the following respect: Failure to ensure the general welfare and protection of residents at all times. Provide safe and secure premises, equipment and staffing which ensures the general welfare and protection of residents at all times through the provision of adequate security and all other protective measures as may be required. Ensure all protective measures currently in place are implemented at all times and that staff are familiar with and knowledgeable on all such measures. Establish clear policies and procedures on the provision and ongoing review of security and protection of residents and staff under health and safety and all other relevant legislative requirements. Ensure all staff are knowledgeable in respect of these policies and procedures. Establish safe systems for monitoring and reviewing all safety systems and protective measures put in place. Establish a system which audits and reviews such safety systems and protective measures on a regular basis and no less frequently than annually. Initiate an immediate and thorough review of all aspects of the premises and equipment both internal and external and make a report on these reviews to the Authority within three months of receipt of this report. This review to be undertaken by persons with relevant expertise and qualifications and to Page 23 of 40

25 include recommendations for improvement within reasonable timeframes. Undertake to implement all recommendations made by the qualified persons in the review within a reasonable timeframe to be agreed by the Authority. Reference: Health Act, 2007 Regulation 19: Premises Standard 25: Physical Environment Please state the actions you have taken or are planning to take with timescales: Timescale: Provider s response: Sensory lighting was installed. A key code access panel has been fitted to the back door (staff entrance) Window restrictors to be fitted to all windows. 27 September /01/2011) May 2011 Review completed - report received from crime prevention officer based on his security survey on 9 February While this report was help it focused primarily on general security matters. The steps taken by the provider are first and foremost to ensure the safety of the resident (and staff). Security installation firms contacted. CCTV and a variety of alarm types installed or being installed. Fence at the back of the back garden apparently belongs to the adjacent HSE centre. Contacted-will not fund a replacement fence. The nursing home will replace the fence. This area is secure in that there is a fence behind this there is no access to the nursing home from this point. A maintenance policy was developed. April/May 2011 April/May 2011 to be conformed by the contractor 28 February 2011 Page 24 of 40

26 5. The provider has failed to comply with a regulatory requirement in the following respect: The emergency plan in place was not comprehensive enough to guide staff on the procedures to follow in all emergency situations. The plan did not include details of all the resources available, specific contact details and arrangements to evacuate residents if required. Develop a comprehensive emergency plan for responding to all types of emergencies including loss of power and heat. Ensure all resources available, specific contact details and arrangements to evacuate residents if required are included. Ensure all staff are knowledgeable in respect of the emergency plan and competent in terms of the implementation of the plan. Establish a system to review the emergency plan on a regular basis and no less frequently than every three months. Reference: Health Act, 2007 Regulation 31: Risk Management Procedures Standard 26: Health and Safety Please state the actions you have taken or are planning to take with timescales: Providers Response: Revised emergency plan in place. Timescale: April/May 2011 To be disseminated to all staff. Next revision required 31 July Page 25 of 40

27 6. The provider has failed to comply with a regulatory requirement in the following respect: There was not suitable and sufficient care to maintain residents welfare and wellbeing in regard to behaviour that challenges. Implement the Challenging Behaviour policy in full and develop individual assessment and individual intervention plans for all residents who present with behaviour that challenges. Review supervision systems and practices in place to manage challenging behaviour in communal and private bedroom areas which ensures safety and also respects the privacy and dignity of all residents. Establish a system which audits and reviews implementation of the policy and disseminates learning to all staff. Reference: Health Act, 2007 Regulation 6: General Welfare and Protection Standard 21: Responding to Behaviour that is Challenging Please state the actions you have taken or are planning to take with timescales: Timescale: Provider s response: Challenging behaviour training (two full day courses) has taken place for nursing and care staff last year. A new policy on challenging behaviour was put in place and disseminated to staff. Care staff were given guidance on behaviour that challenges by the CNM and nursing staff. Behaviour charts are being used to record behaviour that challenges to monitor same, and attempt to predict trends in order to improve the management of these behaviours. The Cohen Mansfield Inventory of challenging behaviour is also being used to identify triggers for challenging behaviour. Root causes of challenging behaviour, e.g. poor communication, are being identified. The CNM is sourcing communication, pictorial cards which may help residents who have poor communication skill, and hence lessen frustration which can lead to challenging behaviour. Ongoing April Page 26 of 40

28 The care plans of residents who present with challenging behaviour have been reviewed by the PIC and behavioural management strategies have been further developed for all residents in conjunction with the appropriate professionals and same will be recorded. Challenging behaviour record is in place for all residents who present with with challenging behaviour. Policy was adjusted accordingly, in particular review completed by GP and psychiatrist for residents presenting with challenging behaviour. A strategy for monitoring of communal areas has been put in place and the implementation is recorded on our new allocation sheet. We are currently in the process of developing an Audit form for all accidents/incidents and also risk assessments. Challenging behaviour records are updated on a regular basis and reviewed to ensure that challenging behaviour policy is being implemented. 7. The provider has failed to comply with a regulatory requirement in the following respect: Staff did not demonstrate knowledge of the procedures to be followed in the case of a fire. Adequate arrangements for the safe evacuation of all persons were not in place. Ensure by means of fire drills and practices at suitable intervals that all persons working in the centre are aware of and competent in the procedures to be followed in the event of a fire. Establish a system of regular review and audit of all fire practices and procedures which includes determination of staff knowledge. Where reasonably practicable ensure residents are aware of the procedures to be followed in the event of a fire. Reference: Health Act, 2007 Regulation 32: Fire Precautions and Records Standard 26: Health and Safety Page 27 of 40

29 Please state the actions you have taken or are planning to take following the inspection with timescales: Provider s response: All staff received fire training last year (August). All newly joined staff had induction training regarding fire and safety. Also all staff are requested to read the emergency plan to ensure the procedures followed in the event of a fire are followed. Formal fire training will be conducted for staff by the end of April. Maintaining an in house fire safety register which includes daily fire door checks, weekly fire alarm checks and fire drills. All fire safety measures were reviewed by company on 8/03/2011. All ski sheets are in place. Reviews of staff knowledge of fire safety to take place quarterly Timescale: Next assessment May The person in charge has failed to comply with a regulatory requirement in the following respect: Initial and continuous assessment, monitoring and evaluation of residents changing needs was not reflected in the care plans. Care plans, risk assessments and nursing evaluations were not linked and are not consistent. Care plans were not specific enough to address and manage the identified need of the residents. Ensure each resident has their needs set out in an individual care plan and keep it under formal review as required by the resident s changing needs or circumstances and no less frequently than every three months. Put systems in place to ensure that all residents identified needs are set out in an individual care plan developed and agreed with each resident. Ensure that all issues such as falls, risks or challenging behaviour are addressed in the care plan and that the care plan is adequately specific to address the need identified. Ensure that care plans in place consistently reflect residents current health status. Reference: Health Act, 2007 Regulation 8: Assessment and Care Plan Standard 10: Assessment Page 28 of 40

30 Please state the actions you have taken or are planning to take with timescales: Timescale: Provider s response: New care plan format introduced. Care plan will be updated three monthly. 30 April 2011 Nurses are currently updating the care plans according to the current needs of the resident. Almost completed. All assessments are being updated. 9. The person in charge has failed to comply with a regulatory requirement in the following respect: A comprehensive assessment which ensured each resident s individual needs could be met was not obtained prior to admission. All necessary information relating to the residents health, personal and social care needs is obtained prior to admission. Establish and maintain protocols which ensures appropriate continuity of care for all residents further to admission. Review and audit such systems and processes established to ensure ongoing implementation. Reference: Health Act, 2007 Regulation 8: Assessment and Care Plan Standard 10: Assessment Please state the actions you have taken or are planning to take with timescales: Provider s response: Timescale: Admission policy and procedures are in place. Comprehensive assessment is in place to ensure all needed information (physical and social) are collected when a resident admit to the nursing home. Following a referral, the person in charge visits the resident at their home or in hospital, if they are unable to visit the nursing home, and completes a pre assessment form. Page 29 of 40

31 At this time, the resident s care needs are reviewed and the extent to which the resident s needs can be met by the nursing home is assessed. The person in charge meets the resident, their family and carers. Where possible, the new resident is invited to visit the nursing home. An admission date, a fee rate and a contract of care is then agreed. On the admission date, an admission record and physical and social assessment is completed by a staff nurse in agreement with the resident, family or carer. The new resident s individualised care plan, which includes a general risk assessment, is completed by the staff nurse within 48 hours. Nursing staff inform the GP that the new resident has arrived. The kitchen is advised about special diets. Will review the same according to the changing needs of the resident. 10. The provider and person in charge have failed to comply with a regulatory requirement in the following respect: Appropriate and timely access to relevant health care services based on residents assessed needs was not facilitated. Regular three monthly reviews of residents general medical condition and medications by a general practitioner for all residents were not in place. Ensure all residents are facilitated to access relevant health care services as may be required. Ensure all residents are provided with appropriate medical care which includes regular three monthly reviews of residents general condition and medication. Provide such services as may be required or enter into discussion with the health service executive to ensure the ongoing provision of services and/or supports which meets the needs of all residents in the current residents profile. Ensure that records are maintained of all actions referrals, recommendations and follow up appointments in a complete manner. Page 30 of 40